ORIGINALARTICLE

DIAGNOSTIC ACCURACY OF COLOR DOPPLER ULTRASONOGRAPHY IN DIFFERENTIATING

BENIGN AND MALIGNANT CERVICAL LYMPH NODES KEEPING HISTOPATHOLOGY AS GOLD

STANDARD

Jawad Ali¹, Mehreen Samad², Ghazala Wahid³, Faryal Bashir⁴, Muhammad Waleed Khan¹, Kiran Zafar¹

How to cite this article

ABSTRACT

OBJECTIVE

Ali J, Samad M, Wahid G, Bashir F,

Khan MW, Zafar K. Diagnostic

Accuracy of Color Doppler

Ultrasonography in Dierentiating

Benign and Malignant Cervical

Lymph Nodes Keeping Histooathology

as Gold Standard. J Gandhara Med Dent

Sci. 2026;13(3): 59-63.

This study aimed to assess the diagnostic accuracy of Color Doppler

Ultrasonography (CDUS) for dierentiating benign from malignant cervical

lymph nodes, with histopathological correlation.

METHODOLOGY

A prospective cross-sectional study was conducted at the Department of

Radiology, MTI–Hayatabad Medical Complex, Peshawar. A total of 235

consecutive patients with clinically suspected cervical lymphadenopathy

underwent Color Doppler ultrasonography followed by histopathological

conrmation, where clinically indicated. Diagnostic performance measures,

including sensitivity, specicity, PPV, NPV, and diagnostic accuracy, along

with their 95% condence intervals, were calculated.

https://doi.org/10.37762/jgmds.13-3.838

Date of Submission: 17-12-2025

Date Revised:

Date Acceptance:

04-06-2026

18-06-2026

RESULTS

CDUS classied 87 (37.0%) lymph nodes as malignant and 148 (63.0%) as

benign. The histopathological results showed 94 (40.0%) malignant and 141

(60.0%) benign lymph nodes. The diagnostic performance of CDUS showed

87.2% sensitivity, 96.5% specicity, 94.3% PPV, 91.9% NPV, and 92.8%

diagnostic accuracy. The participants' mean age was 44.40 ± 15.65 years,

with a female predominance (54.0%). Exploratory stratied analysis

demonstrated numerically comparable diagnostic performance across age

and gender categories; these observations were descriptive and not formally

compared statistically.

¹Trainee Medical Ocer, Department

of Radiology, Hayatabad Medical

Complex, Peshawar

²Professor Department of Radiology,

Hayatabad Medical Complex, Peshawar

⁴Specialist Registrar, Department of

Radiology, Hayatabad Medical

Complex, Peshawar

CONCLUSION

CDUS demonstrated high diagnostic performance and may serve as a useful

rst-line imaging modality for evaluation of cervical lymphadenopathy,

particularly in resource-limited settings; however, histopathological

conrmation remains necessary in equivocal cases.

KEYWORDS: Cervical Lymphadenopathy, Color Doppler, Diagnostic

Accuracy, Histopathology, Sensitivity, Specicity

Correspondence

³Ghazala Wahid, Associate Professor,

Department of Radiology, Hayatabad

Medical Complex, Peshawar

+92-321-9861964

ghazalawahid3@gmail.com

INTRODUCTION

clinical examination. Although the clinical examination

provides initial insight, its subjectivity and low

Cervical lymphadenopathy, or swelling of the neck

lymph nodes, is one of the most prevalent clinical

manifestations in primary care, otolaryngology, and

oncology settings. There are several causes of the

illness, ranging from benign, self-limiting conditions

such as reactive hyperplasia caused by bacterial or viral

infections to more severe pathological processes such as

sensitivity for detecting deeply embedded or slightly

enlarged nodes diminish its reliability.⁴Cross-sectional

imaging techniques, such as MRI (magnetic resonance

imaging) and CT (computed tomography), provide

excellent anatomical detail. However, their usefulness

is often limited by considerable drawbacks, e.g., cost,

limited availability in low-resource or remote settings,

and exposure to ionizing radiation from CT.⁵

Furthermore, they primarily oer morphological data,

with little ability to detect the nodal vascularity, a

crucial dierence between benign and malignant

lymphoma,

metastatic

carcinoma,

and

lymphadenitis.¹Accurate diagnosis of the type of

enlarged lymph node is more dicult than just

identifying them. Prognostic categorization is crucial

for providing appropriate follow-up care and preventing

invasive procedures.²In oncology and in general head

and neck tumors, the presence of malignant cervical

lymphadenopathy is crucial for staging, planning

management, and predicting the patient's prognosis.³

The diagnosis of cervical lymphadenopathy involves

tissue diagnosis, various imaging modalities, and

processes.⁶

this

diagnostic

landscape,

Ultrasonography (US) has become a very useful

diagnostic tool. It is widely accessible, non-invasive,

reasonably priced, and radiation-free.⁷It provides

resolution real time imaging of

outstanding high-

superficial organs, such as cervical lymph nodes,

permitting an extensive assessment of morphological

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Diagnostic Accuracy of Color Doppler Ultrasonography in Dierentiating

features, including size, shape, cortical hypertrophy, pathologists. The results are anticipated to support

hilum preservation, margin contour, and echogenicity. diagnostic procedures, enhance patient care pathways,

Due

the

advancement

of Color

Doppler and validate CDUS's function as a rst-line imaging

in the assessment of cervical

Ultrasonography (CDUS), this structural evaluation modality

now includes a functional component. As a reection of lymphadenopathy, particularly in situations where

their distinctive physiological design, benign reactive access to healthcare resources is crucial.

nodes typically demonstrate preserved hilar vascularity.

In contrast, abnormal vascular patterns, such as

peripheral or mixed vascularity, are often seen in

METHODOLOGY

malignant nodes, whether caused by lymphoma or The study employed a cross-sectional design and was

metastatic deposits. This is because the neo- conducted at the Diagnostic Radiology Department,

vascularization associated with tumor growth aects MTI-Hayatabad Medical Complex, Peshawar. The

the normal hilar blood supply.⁸Additional malignant study duration was 6 months following ethical approval

findings on CDUS include a round shape, increased

cortical thickness, and loss of the echogenic fatty

hilum.⁹The reported diagnostic performance of CDUS

(IRB Ref: 1784). A total of 235 consecutive patients

aged 18–70 years presenting with clinically suspected

cervical lymphadenopathy were enrolled using a non-

probability consecutive sampling technique. The

sample size was calculated using the WHO sample size

calculator, assuming an expected prevalence of 23%, a

sensitivity of 83.3%, a specicity of 79.6%, and a 10%

margin of error. CDUS examination is performed for

each participant, followed by histopathological

examination of the lymph nodes, to calculate

sensitivity, specicity, positive predictive value (PPV),

negative predictive value (NPV), and overall diagnostic

in the

literature

has demonstrated

signicant

inconsistency despite these well-described features.

According to research by Khanal et al. (2021), CDUS

has 83.3% sensitivity and 79.6% specicity compared

with ne-needle aspiration cytology (FNAC).¹⁰Another

study revealed dierences in how CDUS results were

interpreted, demonstrating inter-observer variability and

the lack of widely established diagnostic standards.⁴

This discrepancy presents a clinical challenge and

emphasizes

the

necessity

continuing,

accuracy. Participants with

history of known

methodologically sound research to conrm the

diagnostic accuracy of CDUS, particularly in a variety

of patient demographics and clinical settings. Tissue

diagnosis remains the gold standard for lymph node

malignancy under treatment, previous neck surgery, or

radiotherapy were excluded. Socioeconomic status was

recorded as

demographic variable based on

participants' reported monthly household income and

categorized into low, middle, and high groups

according to predened study categories. After

obtaining informed consent, all participants underwent

Color Doppler ultrasonography (CDUS) examination

performed by experienced radiologists blinded to

histopathological results. All ultrasound examinations

were performed using a GE LOGIQ S8 ultrasound

machine equipped with a 7-12 MHz high-frequency

linear transducer, and a structured reporting pro forma

was used for all examinations. Lymph nodes were

assessed for morphology, including size, short-axis

diameter, long-to-short axis ratio, shape, margins,

echogenic hilum, cortical thickness, nodal borders,

internal necrosis, calcication, and vascularity pattern,

classified as hilar, peripheral, mixed, or avascular.

Benign lymph nodes were generally characterized by

oval morphology and preserved echogenic hilum

(Figure 1). Nodes were classied as malignant when at

least three predened suspicious sonographic features

were present, including round conguration (L/S ratio

<2), absent echogenic hilum, peripheral or mixed

vascularity, cortical thickening >3 mm, irregular

margins, or intranodal necrosis (Figure 2). Two

consultant radiologists with more than ve years of

head and neck imaging experience independently

pathology, as it provides

denitive histologic

diagnosis. Though FNAC is a less invasive option,

sample errors and equivocal results are common,

especially

nodes

with

brosis

cystic

degeneration.²Excisional biopsy is the gold standard for

diagnosis because it provides a detailed architectural

assessment, albeit at the cost of greater invasiveness.

Consequently, this indisputable benchmark must be

used to assess the accuracy of each new diagnostic test.

The availability of modern imaging techniques such as

CT and MRI is frequently limited in health care settings

with the least resources, as seen in many deprived

nations.⁵There is an urgent need for a precise and

accessible diagnostic tool. With its aordability and

portability, CDUS has immense potential to close this

gap by serving as a valuable triage tool to determine

whether patients actually need more expensive imaging

or invasive biopsy.⁵Hence, using histological

validation as the gold standard, the main purpose of this

study was to establish the diagnostic accuracy of Color

Doppler Ultrasonography in dierentiating benign from

malignant cervical lymph nodes. This study aims to

provide high-quality evidence on the clinical value of

CDUS using a robust cross-sectional design with a

sufcient sample size and blinding of radiologists and

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Diagnostic Accuracy of Color Doppler Ultrasonography in Dierentiating

Figure 2: Sonographic Appearance of a Malignant Cervical

reviewed 30 randomly selected cases to improve

observer calibration. Concordance between reviewers

was assessed during calibration through case-wise

comparison of nal classications, and discordant

interpretations were resolved by consensus discussion

before final analysis. Formal interobserver agreement

statistics (e.g., Cohen's kappa) were not performed

because quantitative reproducibility assessment was

beyond the predened objectives of the present study.

The same nodes were then sent to a senior pathologist

who was blinded to ultrasound ndings and clinical

radiology reports to minimize interpretation bias.

Histopathological diagnosis was established using

either core needle biopsy or excisional biopsy,

according to routine clinical indications and the treating

clinician's preference rather than the study protocol, and

all specimens underwent histopathological evaluation.

Benign-appearing lymph nodes were biopsied because

Lymph Node Showing Rounded Morphology and an Absent Fatty

Hilum

RESULTS

all

enrolled

patients

had

persistent

cervical

This study included 235 patients in the nal analysis

with a mean age of 44.40 ± 15.65 years. The cohort

demonstrated a slight female predominance (54.0%),

and the majority of participants (60.4%) were under 50

years of age.

lymphadenopathy with clinical suspicion requiring

tissue diagnosis as part of routine clinical management.

For statistical analysis, SPSS version 23.0 was used.

Continuous variables were reported as mean ± standard

deviation, and categorical variables as frequencies and

percentages. Diagnostic accuracy measures, including

sensitivity, specicity, positive predictive value (PPV),

negative predictive value (NPV), and overall diagnostic

accuracy, and corresponding 95% condence intervals,

were calculated using a 2×2 contingency table. As the

study used dichotomous classication rather than

continuous probability outputs, receiver operating

characteristic (ROC) analysis was not performed.

Multivariable adjustment was not undertaken because

the study objective focused on estimating diagnostic

performance rather than identifying independent

predictors. Stratied analyses by age and gender were

exploratory and descriptive.

Table 1: Baseline Demographic and Clinical Characteristics of

Study Population (n=235)

Variable

Category

Value

Age (Years)

44.40 ± 15.65 (Mean ± SD)

12.83 ± 7.11 (Mean ± SD)

Duration of Symptoms (Months)

< 50 Years 142 (60.4%)

≥ 50 Years 93 (39.6%)

Male

Female

High

Age Group

108 (46.0%)

127 (54.0%)

20 (8.5%)

121 (51.5%)

94 (40.0%)

Gender

Socioeconomic Status Middle

Low

Table 2: Contingency Analysis and Diagnostic Performance of

Color Doppler Ultrasonography Versus Histopathology (n=235)

Figure 1: Sonographic Appearance of a Benign Cervical Lymph

Node Demonstrating Preserved Fatty Hilum and Oval

Morphology

2A. Contingency Table

Histopathology

Total

Malignant

Benign

CDUS Malignant

CDUS Benign

Total

148

235

136

141

2B. Diagnostic Performance Measures

(%)

Diagnostic Parameter

Estimate

95% Condence

Interval

Sensitivity

Specificity

87.2

96.5

78.8-93.2

91.9-98.8

Positive Predictive Value(PPV) 94.3

Negative Predictive Value(NPV) 91.9

87.1-98.1

86.3-95.7

Diagnostic Accuracy

92.8

88.7-95.7

Abbreviations: CDUS

Color

Doppler

Ultrasonography; PPV = Positive Predictive Value;

NPV = Negative Predictive Value

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Diagnostic Accuracy of Color Doppler Ultrasonography in Dierentiating

Table 3: Stratied Analysis of CDUS Diagnostic Accuracy

reect dierences in study populations, reference

standards, ultrasound protocols, and case selection

across studies rather than a true dierence in diagnostic

performance.¹⁵The high diagnostic value of specic

sonographic features observed in our study, particularly

vascular patterns, is supported by prior studies. A recent

meta-analysis by Jisun Hwang et al. (2025), focusing on

pediatric cervical lymphadenopathy, reported abnormal

vascularity as one of the most specic ultrasound

features for predicting malignancy, with a pooled

specificity of 0.91 (95% CI: 0.82-0.97).¹⁶These

findings are generally consistent with our observation

of CDUS's high specicity and support the role of

vascular assessment in cervical lymph node evaluation

across dierent populations. Exploratory subgroup

analyses demonstrated numerical variation in diagnostic

performance across demographic categories. However,

the present study was not designed or powered to

establish subgroup eects, and no formal comparative

statistical testing was undertaken. Therefore, these

observations should be interpreted cautiously and

should not be considered evidence of true biological or

clinical dierences. Future studies with predened

subgroup analyses are needed to evaluate potential

variation in diagnostic performance further. Despite its

demonstrated ecacy, it is important to acknowledge

the inherent limitations of CDUS. Its operator-

Subgroup

Sensitivity Specificity PPV NPV Diagnostic

Accuracy

Age < 50 Years 88.2%

(n=142)

96.7%

96.0%

93.8 93.6

93.6%

91.4%

Age ≥ 50 Years 86.0%

94.9 % 88.9

(n=93)

(n=108)

Male

84.4%

89.8%

91.3%

96.1%

95.0 75.0

86.7%

93.7%

(n=127)

Female

93.6 93.7

DISCUSSION

Our study demonstrates an overall accuracy of 92.8%,

with a sensitivity of 87.2% and signicant specicity of

96.5%. The ndings indicate that CDUS is a very

reliable diagnostic tool. These results validate CDUS as

a useful and consistent initial approach for evaluating

cervical lymphadenopathy. One of the major ndings of

this study was the high specicity (96.5%) of CDUS; it

is reasonably reliable in correctly identifying benign

nodes, thereby reducing the number of false-positive

results.¹¹CDUS can eciently triage patients by ruling

out malignancy, reducing the number of invasive,

expensive biopsy procedures. In addition to reducing

procedural morbidity and patient anxiety, this

maximizes the use of healthcare resources, which is

crucial in any situation, particularly in those with

limited resources.¹²This utility is further supported by

the high positive predictive value (PPV) of 94.3%,

indicating that when CDUS features point to

malignancy, there is a very high likelihood of

histopathological conrmation, giving clinicians the

confidence to proceed with additional management or

intervention. Our ndings strongly align with the

growing body of modern literature. A recent study by

reported a sensitivity of 89% and a specicity of 94%

dependency remains

significant factor, as the

acquisition and interpretation of images are strongly

inuenced by the radiologist's skill and experience.¹⁸

Moreover, certain clinical conditions remain to pose

diagnostic challenges. For instance, Tuberculous

lymphadenitis often presents with necrotic or cystic

changes that can be indistinguishable from necrotic

metastatic lymph nodes on conventional CDUS.

for

CDUS

the

Evaluation

cervical

CONCLUSIONS

lymphadenopathy, gures that are strikingly consistent

with our ndings.¹³The authors attributed this

outstanding result to a methodical evaluation of

vascular patterns, particularly the transition from hilar

to peripheral vascularity, which was also an important

diagnostic criterion in our study. In addition, a 2019

study by Zuzana Sedlackova et al. that examined the

use of ultrasound in assessing head and neck lymph

nodes synthesized data from multiple studies and

confirmed the high specicity of sonographic features,

such as Doppler-identified vascular patterns, in

identifying cancerous nodes. The validity and

consistency of CDUS's diagnostic performance across a

range of populations and practice settings are further

supported by the fact that our results fall comfortably

within, and in some cases slightly surpass, the

Color Doppler ultrasonography demonstrated high

diagnostic accuracy in dierentiating benign from

malignant cervical lymph nodes when compared with

histopathology. It showed high sensitivity and

specificity and may serve as a useful rst-line imaging

investigation

the

assessment

cervical

lymphadenopathy. However, CDUS remains operator-

dependent, and certain inammatory conditions,

particularly tuberculous lymphadenitis, may exhibit

overlapping sonographic appearances with malignant

lymphadenopathy.

Therefore,

histopathological

confirmation remains essential in equivocal or clinically

suspicious cases.

LIMITATIONS

performance metrics reported in such thorough

reviews.¹⁴The comparatively higher specicity

observed in our study relative to previous reports may

Although eorts were made to standardize ultrasound

acquisition

and

interpretation,

color

Doppler

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Diagnostic Accuracy of Color Doppler Ultrasonography in Dierentiating

Sha A, Zameer S, Malik MN, Liaqat R, Liaqat B, Liaqat A.

Diagnostic accuracy of ultrasound to dierentiate neoplastic and

non-neoplastic causes of cervical lymphadenopathy taking

histopathology as the gold standard. Pak Armed Forces Med J.

ultrasonography remains operator-dependent and may

show variability across dierent clinical settings. While

observer calibration and consensus review were

incorporated to improve consistency of image

interpretation, formal interobserver agreement statistics

were not performed; therefore, reproducibility across

observers could not be quantitatively assessed. Receiver

https://doi.org/10.51253/pafmj.v73i4.6234.

2023;73(4):1024-1027.

10. Misra D, Panjwani S, Rai S, Misra A, Prabhat M, Gupta P, et al.

Diagnostic efcacy of color Doppler ultrasound in evaluation of

cervical

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Jawad Ali - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Final Approval

Mehreen Samad - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Supervision; Final

Approval

Ghazala Wahid - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Critical Revision; Final Approval

Faryal Bashir - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Muhammad Waleed Khan - Concept & Design; Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Kiran Zafar - Concept & Design; Data Analysis/Interpretation;

Drafting Manuscript; Final Approval

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